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` STATE OF CALIFORNIA* WATER RESOURCES CONTROW ARD ' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM w' TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. TANK 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOBF$rTANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED t2 Ln FARM TANK-YES[:1NO ❑ N FACILITY/SITE NAME WHERE TANK IS INSTALLED:765o S -J O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED II. TANK CONTENTS IF(A.9,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑1 UNLEADED ❑ 2 LEADED 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM ❑3 CHEMICALPRODUCT ❑4 OIL 13/1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.M HAZARDOUS SUBSTANCE STORED A C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D FKFOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN ❑99 OTHER F-1NGLE WALLED ❑4 SECONDARY CONTAINMENT TEELIIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOLCOMPATIBLE FRP RONZE10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER UBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR ❑5 GLASSUNING ❑6 UNUNED ❑95 UNKNOWN LINING ❑ 13 LINING MATERIAL COMPATIBLEWITH 100%METHANOL? YES ❑NO W OTHER D.CORROSION ❑I POLYEIHLENEWRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. r' P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 I P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK RULED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATEDREMAINGI INERT MATERIAL? ❑YES [] NO SUBSTANCE REMAINING IN GALLONS THIS FOF�� AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# n COUNTY# JURISDICTION AGE / PCHECK# NCY FACILITYID XAPPROVED BY NAME PHONE X WITH AREA CODE176PERMITAPP11OVALDATE PERMIT EXPIRATION DATE FEE CODE AEC PT# BY: PERMIT AMOUNT SURCHARGE AMT. i C / FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY ACILITY/SDITE ATAPLIIR TION, NOGRM 'A, UNLESS A CURRENT FORMA' HAS BEEN FILED